Depression self-management / L’autogestion de la dépression

It’s no secret that successful treatment of depression is challenging in clinical practice. Even in the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) “real-world” clinical trial, the largest of its kind, about one-third of patients failed to achieve remission after four different levels of treatment, involving either medication switching, or augmentation with another medication or cognitive therapy.1 Recurrence is also common, with a rate of 85% after 15-year prospective followup.2 An added complication is that, in both primary and psychiatric care, around 50% of patients with depression stop antidepressant therapy prematurely (within 6 months of starting),3 making it even harder to achieve and sustain remission. Increasingly, depression is being recognized and managed as a chronic disease.2

Empowered patients, better outcomes

So what can clinicians do to keep patients motivated and on track? The key is self-management: actively engaging patients in their treatment through various activities to promote health, treatment adherence, and monitoring of physical, emotional and psychosocial status.4

But patients need help to implement self-management successfully. A growing number of authorities worldwide, including the 2016 updated Canadian Network for Mood and Anxiety Treatments (CANMAT) depression guidelines, are making “supported self-management” (SSM) an essential, evidence-based component of depression care.5 SSM lowers reliance on healthcare providers, increases empowerment and self-efficacy, and is associated with fewer depression symptoms, improved functioning, and possibly lower relapse/recurrence rates.2 For some patients with mild depression, SSM can even replace antidepressants, offering a better risk-benefit ratio at lower cost.6

Help patients help themselves

SSM for depression should include the following elements:6
1. Self-management guide: a workbook or, increasingly, an interactive website, to learn about depression and its management, including coping skills based on cognitive-behavioural therapy (CBT) (Table 1)

3. Encouragement and coaching: by the physician, and also by also allied health professionals (e.g. psychologists, nurses, occupational therapists), peer support workers and groups, family and friends

The latest buzzword in depression management, and a key component of SSM, is measurement-based care (MBC), which uses rating scales to monitor outcomes and support clinical decisions. The 2016 CANMAT guidelines recommend using MBC to monitor not only symptoms, but also functioning, side effects and quality of life.

Overburdened clinicians can rest assured that patient-rated scales are quicker than, and correlate well with, clinician-administered scales.5 With a few steps, MBC can be integrated into even the busiest practice (Table 2).

Table 1. Web resources for patient self-management

• MoodFx (www.moodfx.ca): a free, mobile-friendly web tool developed by the Mood Disorders Centre at UBC Hospital; allows patients to screen for and track depression symptoms, set reminders to check symptoms regularly and before appointments; print, email or show results to doctor on mobile device, and view progress over time with simple charts (English, French)
• Antidepressant Skills Workbook (www.comh.ca/antidepressant-skills/adult): a free self-management guide from Simon Fraser University; contains an overview of depression and its management, and step-by-step instructions on changing patterns that trigger depression; online and downloadable versions (English, French, Punjabi, Chinese, Vietnamese, Farsi) and audiobook versions (English, French)
• Living Life to the Full (www.llttf.com): an interactive web course teaching CBT-based life skills (English)

Table 2. Practice tips for measurement-based care

• Use patient-rated scales.
• Have ready-to-use copies of scales in the office.
• Have patients complete scales in the waiting room, or in an exam room while seeing another patient.
• Use a monitoring summary sheet in the chart.
• Configure a monitoring dashboard in your electronic medical record (EMR).
• Use tracking apps and web sites (for tech-savvy patients).

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About the author

Erin Michalak, PhD, is an Associate Professor and Network Lead of the Collaborative RESearch Team to study psychosocial issues in Bipolar Disorder (CREST.BD), Department of Psychiatry, University of British Columbia.